{"id":71954,"date":"2019-07-22T04:17:49","date_gmt":"2019-07-22T04:17:49","guid":{"rendered":"https:\/\/algomafamilyservices.ca\/programme-dacces-supervise\/"},"modified":"2025-11-28T03:25:08","modified_gmt":"2025-11-28T03:25:08","slug":"programme-dacces-supervise","status":"publish","type":"page","link":"https:\/\/algomafamilyservices.ca\/fr\/programme-dacces-supervise\/","title":{"rendered":"Programme d&rsquo;acc\u00e8s supervis\u00e9"},"content":{"rendered":"<p><div class=\"et_d4_element et_pb_section et_pb_section_0 et_pb_with_background  et_pb_css_mix_blend_mode et_section_regular et_block_section\" >\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_d4_element et_pb_row et_pb_row_0 et_hover_enabled  et_pb_css_mix_blend_mode et_block_row\">\n\t\t\t\t<div class=\"et_d4_element et_pb_column_4_4 et_pb_column et_pb_column_0  et_pb_css_mix_blend_mode et-last-child et_block_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module et_d4_element et_pb_text et_pb_text_0 et_animated  et_pb_text_align_center et_pb_bg_layout_dark\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_text_inner\"><h1><span>Programme d'acc\u00e8s supervis\u00e9<\/span><\/h1><\/div>\n\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\t\n\t\t\t\t\n\t\t\t<\/div><div class=\"et_d4_element et_pb_section et_pb_section_1  et_pb_css_mix_blend_mode et_section_regular et_block_section\" >\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_d4_element et_pb_row et_pb_row_1  et_pb_css_mix_blend_mode et_block_row\">\n\t\t\t\t<div class=\"et_d4_element et_pb_column_4_4 et_pb_column et_pb_column_1  et_pb_css_mix_blend_mode et-last-child et_block_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module et_d4_element et_pb_text et_pb_text_1  et_pb_text_align_left et_pb_bg_layout_light\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_text_inner\"><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_5' style='display:none'><div id='gf_5' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_5' id='gform_5'  action='\/fr\/wp-json\/wp\/v2\/pages\/71954#gf_5' data-formid='5' novalidate>\n        <div id='gf_progressbar_wrapper_5' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<h3 class=\"gf_progressbar_title\">\u00c9tape <span class='gf_step_current_page'>1<\/span> sur <span class='gf_step_page_count'>5<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_20' style='width:20%;'><span>20%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_5_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_5_1\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>FORMULAIRE DE DEMANDE DE VISITE \/ \u00c9CHANGE SURVEILL\u00c9(E)<\/h3>\nPour plus d\u2019informations ou pour obtenir de l\u2019aide pour remplir ce formulaire, contactez le Coordonnateur du programme \u00e0 sap@algomafamilyservices.org ou au (705) 945-5058 poste 2707 ou au 1-800-461-2237 poste 2707.<\/li><li id=\"field_5_2\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_2'>Date de la demande<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Obligatoire<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input aria-describedby='field_5_2_dmessage' name='input_2' id='input_5_2' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_5_2_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_5_2_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_2' class='gform_hidden' value='https:\/\/algomafamilyservices.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_5_3\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_3'>Service demand\u00e9<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Obligatoire<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_3' id='input_5_3' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>S\u00e9lectionnez un service<\/option><option value='Visites' >Visites<\/option><option value='\u00c9changes' >\u00c9changes<\/option><option value='Visites virtuelles' >Visites virtuelles<\/option><\/select><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_5_30' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_2' class='gform_page' data-js='page-field-id-30' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_5_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_5_6\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Obligatoire<\/span><\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_6'>\n                            \n                            <span id='input_5_6_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_6.3' id='input_5_6_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_6_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_6_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_6.6' id='input_5_6_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_6_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><\/li><li id=\"field_5_5\" class=\"gfield gfield--type-date gfield--input-type-datedropdown gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Date de naissance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Obligatoire<\/span><\/span><\/span><\/label><div id='input_5_5' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_5_5_1_container'><label for='input_5_5_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Mois<\/label><select aria-describedby='field_5_5_dmessage' name='input_5[]' id='input_5_5_1'   aria-required='true'  ><option value=''>Mois<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_5_5_2_container'><label for='input_5_5_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Jour<\/label><select aria-describedby='field_5_5_dmessage' name='input_5[]' id='input_5_5_2'   aria-required='true'  ><option value=''>Jour<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_5_5_3_container'><label for='input_5_5_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Ann\u00e9e<\/label><select aria-describedby='field_5_5_dmessage' name='input_5[]' id='input_5_5_3'   aria-required='true'  ><option value=''>Ann\u00e9e<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_5_8\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Saut de section<\/h2><\/li><li id=\"field_5_9\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_9'>Relation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Obligatoire<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_9' id='input_5_9' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='M\u00e8re' >M\u00e8re<\/option><option value='P\u00e8re' >P\u00e8re<\/option><option value='Autre' >Autre<\/option><\/select><\/div><\/li><li id=\"field_5_10\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_10'>Autre (Veuillez pr\u00e9ciser)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Obligatoire<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_5_10' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_11\" class=\"gfield gfield--type-multiselect gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_11'>Veuillez s\u00e9lectionner<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Obligatoire<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_11[]' id='input_5_11' class='medium gfield_select'   aria-invalid=\"false\" aria-required=\"true\" ><option value='R\u00e9sidence principale' >R\u00e9sidence principale<\/option><option value='Partie visiteuse' >Partie visiteuse<\/option><option value='Garde partag\u00e9e' >Garde partag\u00e9e<\/option><\/select><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_31' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_5_31' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_3' class='gform_page' data-js='page-field-id-31' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_5_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_5_12\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Adresse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Obligatoire<\/span><\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_5_12' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_12_1_container' >\n                                        <input type='text' name='input_12.1' id='input_5_12_1' value=''    aria-required='true'    \/>\n                                        <label for='input_5_12_1' id='input_5_12_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_12_2_container' >\n                                        <input type='text' name='input_12.2' id='input_5_12_2' value=''     aria-required='false'   \/>\n                                        <label for='input_5_12_2' id='input_5_12_2_label' class='gform-field-label gform-field-label--type-sub '>Adresse ligne 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_12_3_container' >\n                                    <input type='text' name='input_12.3' id='input_5_12_3' value=''    aria-required='true'    \/>\n                                    <label for='input_5_12_3' id='input_5_12_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_12_4_container' >\n                                        <input type='text' name='input_12.4' id='input_5_12_4' value=''      aria-required='true'    \/>\n                                        <label for='input_5_12_4' id='input_5_12_4_label' class='gform-field-label gform-field-label--type-sub '>\u00c9tat\/Province\/R\u00e9gion<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_12_5_container' >\n                                    <input type='text' name='input_12.5' id='input_5_12_5' value=''    aria-required='true'    \/>\n                                    <label for='input_5_12_5' id='input_5_12_5_label' class='gform-field-label gform-field-label--type-sub '>Code postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_12.6' id='input_5_12_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><\/li><li id=\"field_5_13\" class=\"gfield gfield--type-phone gf_left_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_13'>T\u00e9l\u00e9phone r\u00e9sidentiel<\/label><div class='ginput_container ginput_container_phone'><input name='input_13' id='input_5_13' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_14\" class=\"gfield gfield--type-phone gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_14'>Mobile<\/label><div class='ginput_container ginput_container_phone'><input name='input_14' id='input_5_14' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_15\" class=\"gfield gfield--type-phone gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_15'>T\u00e9l\u00e9phone professionnel<\/label><div class='ginput_container ginput_container_phone'><input name='input_15' id='input_5_15' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_16\" class=\"gfield gfield--type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_16'>Courriel<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_16' id='input_5_16' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_5_19\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Autre parent \/ tuteur<\/h3><\/li><li id=\"field_5_20\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Nom<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_20'>\n                            \n                            <span id='input_5_20_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_20.3' id='input_5_20_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_20_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_20_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_20.6' id='input_5_20_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_20_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><\/li><li id=\"field_5_22\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_22'>Relation<\/label><div class='ginput_container ginput_container_select'><select name='input_22' id='input_5_22' class='medium gfield_select'     aria-invalid=\"false\" ><option value='M\u00e8re' >M\u00e8re<\/option><option value='P\u00e8re' >P\u00e8re<\/option><option value='Autre (veuillez pr\u00e9ciser)' >Autre (veuillez pr\u00e9ciser)<\/option><\/select><\/div><\/li><li id=\"field_5_23\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_23'>Autre (Veuillez pr\u00e9ciser)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Obligatoire<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_5_23' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_21\" class=\"gfield gfield--type-multiselect field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_21'>S\u00e9lectionnez tout ce qui s\u2019applique<\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_21[]' id='input_5_21' class='medium gfield_select'   aria-invalid=\"false\"  ><option value='R\u00e9sidence principale' >R\u00e9sidence principale<\/option><option value='Partie visiteuse' >Partie visiteuse<\/option><option value='Garde partag\u00e9e' >Garde partag\u00e9e<\/option><\/select><\/div><\/li><li id=\"field_5_43\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Informations sur les enfants<\/h3><\/li><li id=\"field_5_41\" class=\"gfield gfield--type-list field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Veuillez cliquer sur (+) pour ajouter un enfant<\/label><style type=\"text\/css\">\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons {\n\t\t\t\t\t\t\tvertical-align: middle !important;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons img {\n\t\t\t\t\t\t\tbackground-color: transparent !important;\n\t\t\t\t\t\t\tbackground-position: 0 0;\n\t\t\t\t\t\t\tbackground-size: 16px 16px !important;\n\t\t\t\t\t\t\tbackground-repeat: no-repeat;\n\t\t\t\t\t\t\tborder: none !important;\n\t\t\t\t\t\t\twidth: 16px !important;\n\t\t\t\t\t\t\theight: 16px !important;\n\t\t\t\t\t\t\topacity: 0.5;\n\t\t\t\t\t\t\ttransition: opacity .5s ease-out;\n\t\t\t\t\t\t    -moz-transition: opacity .5s ease-out;\n\t\t\t\t\t\t    -webkit-transition: opacity .5s ease-out;\n\t\t\t\t\t\t    -o-transition: opacity .5s ease-out;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons a:hover img {\n\t\t\t\t\t\t\topacity: 1.0;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\t<\/style><div class='ginput_container ginput_container_list ginput_list'><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_41_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_41_col_2' class='gfield_list_col_even' \/><col id='gfield_list_41_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_41_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th scope=\"col\">Pr\u00e9nom<\/th><th scope=\"col\">Nom de famille<\/th><th scope=\"col\">Date de naissance (DOB)<\/th><td>&nbsp;<\/td><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_41_cell1' data-label='Pr\u00e9nom'><input title='Pr\u00e9nom'aria-invalid='false'   aria-label='Pr\u00e9nom, Ligne 1' data-aria-label-template='Pr\u00e9nom, Ligne {0}' type='text' name='input_41[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_41_cell2' data-label='Nom de famille'><input title='Nom de famille'aria-invalid='false'   aria-label='Nom de famille, Ligne 1' data-aria-label-template='Nom de famille, Ligne {0}' type='text' name='input_41[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_41_cell3' data-label='Date de naissance (DOB)'><input title='Date de naissance (DOB)'aria-invalid='false'   aria-label='Date de naissance (DOB), Ligne 1' data-aria-label-template='Date de naissance (DOB), Ligne {0}' type='text' name='input_41[]' value=''   \/><\/td><td class='gfield_list_icons'>   <a href='javascript:void(0);' class='add_list_item ' aria-label='Ajouter une autre ligne' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)'><img src='https:\/\/algomafamilyservices.ca\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' alt='' title='Ajouter une nouvelle ligne' \/><\/a>   <a href='javascript:void(0);' class='delete_list_item' aria-label='Supprimer cette ligne' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\"><img src='https:\/\/algomafamilyservices.ca\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' alt='' title='Supprimer cette ligne' \/><\/a><\/td><\/tr><\/tbody><\/table><\/div><\/fieldset><\/li><li id=\"field_5_25\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Informations de contact d\u2019urgence<\/h3><\/li><li id=\"field_5_26\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Nom<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_26'>\n                            \n                            <span id='input_5_26_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_26.3' id='input_5_26_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_26_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_26_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_26.6' id='input_5_26_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_26_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><\/li><li id=\"field_5_27\" class=\"gfield gfield--type-phone gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_27'>T\u00e9l\u00e9phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_27' id='input_5_27' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_29\" class=\"gfield gfield--type-phone gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_29'>Mobile<\/label><div class='ginput_container ginput_container_phone'><input name='input_29' id='input_5_29' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_28\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_28'>Lien de parent\u00e9<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_5_28' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_32' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_5_32' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_4' class='gform_page' data-js='page-field-id-32' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_5_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_5_34\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Informations sur l\u2019avocat du demandeur<\/h3><\/li><li id=\"field_5_47\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Nom<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_47'>\n                            \n                            <span id='input_5_47_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_47.3' id='input_5_47_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_47_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_47_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_47.6' id='input_5_47_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_47_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><\/li><li id=\"field_5_36\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Adresse<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_5_36' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_36_1_container' >\n                                        <input type='text' name='input_36.1' id='input_5_36_1' value=''    aria-required='false'    \/>\n                                        <label for='input_5_36_1' id='input_5_36_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_36_2_container' >\n                                        <input type='text' name='input_36.2' id='input_5_36_2' value=''     aria-required='false'   \/>\n                                        <label for='input_5_36_2' id='input_5_36_2_label' class='gform-field-label gform-field-label--type-sub '>Adresse ligne 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_36_3_container' >\n                                    <input type='text' name='input_36.3' id='input_5_36_3' value=''    aria-required='false'    \/>\n                                    <label for='input_5_36_3' id='input_5_36_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_36_4_container' >\n                                        <select name='input_36.4' id='input_5_36_4'     aria-required='false'    ><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du Nord-Ouest' >Territoires du Nord-Ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' selected='selected'>Ontario<\/option><option value='\u00cele du Prince-\u00c9douard' >\u00cele du Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_5_36_4' id='input_5_36_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_36_5_container' >\n                                    <input type='text' name='input_36.5' id='input_5_36_5' value=''    aria-required='false'    \/>\n                                    <label for='input_5_36_5' id='input_5_36_5_label' class='gform-field-label gform-field-label--type-sub '>Code postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_36.6' id='input_5_36_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><\/li><li id=\"field_5_37\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_37'>T\u00e9l\u00e9phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_37' id='input_5_37' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_38\" class=\"gfield gfield--type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_38'>Courriel<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_38' id='input_5_38' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_5_44\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Bureau de l\u2019avocat des enfants (si impliqu\u00e9)<\/h3><\/li><li id=\"field_5_35\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Nom<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_35'>\n                            \n                            <span id='input_5_35_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_35.3' id='input_5_35_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_35_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_35_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_35.6' id='input_5_35_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_35_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><\/li><li id=\"field_5_46\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_46'>T\u00e9l\u00e9phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_46' id='input_5_46' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_39' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_5_39' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_5' class='gform_page' data-js='page-field-id-39' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_5_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_5_48\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>IMPLICATION DE LA SOCI\u00c9T\u00c9 D\u2019AIDE \u00c0 L\u2019ENFANCE<\/h3><\/li><li id=\"field_5_49\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >La Soci\u00e9t\u00e9 d\u2019aide \u00e0 l\u2019enfance est-elle actuellement impliqu\u00e9e dans votre famille<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_49'>\n\t\t\t<li class='gchoice gchoice_5_49_0'>\n\t\t\t\t<input name='input_49' type='radio' value='Oui'  id='choice_5_49_0'    \/>\n\t\t\t\t<label for='choice_5_49_0' id='label_5_49_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_49_1'>\n\t\t\t\t<input name='input_49' type='radio' value='Non'  id='choice_5_49_1'    \/>\n\t\t\t\t<label for='choice_5_49_1' id='label_5_49_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_5_52\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_3col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >S\u00e9lectionner<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_5_52'><li class='gchoice gchoice_5_52_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.1' type='checkbox'  value='Enqu\u00eate \/ pr\u00e9occupations de protection'  id='choice_5_52_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_52_1' id='label_5_52_1' class='gform-field-label gform-field-label--type-inline'>Enqu\u00eate \/ pr\u00e9occupations de protection<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_52_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.2' type='checkbox'  value='Volontairement'  id='choice_5_52_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_52_2' id='label_5_52_2' class='gform-field-label gform-field-label--type-inline'>Volontairement<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_52_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.3' type='checkbox'  value='Autre'  id='choice_5_52_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_52_3' id='label_5_52_3' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_5_53\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Nom de l\u2019intervenant<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_53'>\n                            \n                            <span id='input_5_53_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_53.3' id='input_5_53_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_53_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_53_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_53.6' id='input_5_53_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_53_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><\/li><li id=\"field_5_54\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_54'>T\u00e9l\u00e9phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_54' id='input_5_54' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_55\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_3col field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Informations juridiques<\/label><div class='gfield_description' id='gfield_description_5_55'>Informations juridiques<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_5_55'><li class='gchoice gchoice_5_55_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.1' type='checkbox'  value='Ordonn\u00e9 par le tribunal'  id='choice_5_55_1'   aria-describedby=\"gfield_description_5_55\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_1' id='label_5_55_1' class='gform-field-label gform-field-label--type-inline'>Ordonn\u00e9 par le tribunal<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_55_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.2' type='checkbox'  value='Protection de l\u2019enfance'  id='choice_5_55_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_2' id='label_5_55_2' class='gform-field-label gform-field-label--type-inline'>Protection de l\u2019enfance<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_55_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.3' type='checkbox'  value='Avocat'  id='choice_5_55_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_3' id='label_5_55_3' class='gform-field-label gform-field-label--type-inline'>Avocat<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_55_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.4' type='checkbox'  value='O.C.L.'  id='choice_5_55_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_4' id='label_5_55_4' class='gform-field-label gform-field-label--type-inline'>O.C.L.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_55_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.5' type='checkbox'  value='Auto-r\u00e9f\u00e9rence'  id='choice_5_55_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_5' id='label_5_55_5' class='gform-field-label gform-field-label--type-inline'>Auto-r\u00e9f\u00e9rence<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_55_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.6' type='checkbox'  value='Autre'  id='choice_5_55_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_6' id='label_5_55_6' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_5_56\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_3col field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Raison de la r\u00e9f\u00e9rence<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_5_56'><li class='gchoice gchoice_5_56_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.1' type='checkbox'  value='Pr\u00e9occupation concernant la capacit\u00e9 parentale'  id='choice_5_56_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_56_1' id='label_5_56_1' class='gform-field-label gform-field-label--type-inline'>Pr\u00e9occupation concernant la capacit\u00e9 parentale<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_56_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.2' type='checkbox'  value='Pr\u00e9occupation concernant l\u2019enl\u00e8vement'  id='choice_5_56_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_56_2' id='label_5_56_2' class='gform-field-label gform-field-label--type-inline'>Pr\u00e9occupation concernant l\u2019enl\u00e8vement<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_56_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.3' type='checkbox'  value='Ant\u00e9c\u00e9dents de consommation d\u2019alcool ou de drogues'  id='choice_5_56_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_56_3' id='label_5_56_3' class='gform-field-label gform-field-label--type-inline'>Ant\u00e9c\u00e9dents de consommation d\u2019alcool ou de drogues<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_56_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.4' type='checkbox'  value='Ant\u00e9c\u00e9dents de maladie psychiatrique'  id='choice_5_56_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_56_4' id='label_5_56_4' class='gform-field-label gform-field-label--type-inline'>Ant\u00e9c\u00e9dents de maladie psychiatrique<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_56_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.5' type='checkbox'  value='Violence entre partenaires'  id='choice_5_56_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_56_5' id='label_5_56_5' class='gform-field-label gform-field-label--type-inline'>Violence entre partenaires<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_56_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.6' type='checkbox'  value='Autre'  id='choice_5_56_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_56_6' id='label_5_56_6' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_56_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.7' type='checkbox'  value='Pr\u00e9occupation concernant la maltraitance d\u2019un enfant'  id='choice_5_56_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_56_7' id='label_5_56_7' class='gform-field-label gform-field-label--type-inline'>Concern Regarding Child Abuse<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_56_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.8' type='checkbox'  value='Entrave \u00e0 l\u2019acc\u00e8s par l\u2019une ou l\u2019autre des parties'  id='choice_5_56_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_56_8' id='label_5_56_8' class='gform-field-label gform-field-label--type-inline'>Entrave \u00e0 l\u2019acc\u00e8s par l\u2019une ou l\u2019autre des parties<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_56_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.9' type='checkbox'  value='Absence prolong\u00e9e de l\u2019une ou l\u2019autre des parties'  id='choice_5_56_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_56_9' id='label_5_56_9' class='gform-field-label gform-field-label--type-inline'>Absence prolong\u00e9e de l\u2019une ou l\u2019autre des parties<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_56_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.11' type='checkbox'  value='Conflit non r\u00e9solu entre les parties'  id='choice_5_56_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_56_11' id='label_5_56_11' class='gform-field-label gform-field-label--type-inline'>Conflit non r\u00e9solu entre les parties<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_5_57\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Saut de section<\/h2><\/li><li id=\"field_5_58\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >\u00cates-vous d\u2019accord avec cette demande\u202f?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_58'>\n\t\t\t<li class='gchoice gchoice_5_58_0'>\n\t\t\t\t<input name='input_58' type='radio' value='Oui'  id='choice_5_58_0'    \/>\n\t\t\t\t<label for='choice_5_58_0' id='label_5_58_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_58_1'>\n\t\t\t\t<input name='input_58' type='radio' value='Non'  id='choice_5_58_1'    \/>\n\t\t\t\t<label for='choice_5_58_1' id='label_5_58_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_5_59\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Y a-t-il une ordonnance du tribunal pour l\u2019acc\u00e8s supervis\u00e9\u202f?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_59'>\n\t\t\t<li class='gchoice gchoice_5_59_0'>\n\t\t\t\t<input name='input_59' type='radio' value='Oui'  id='choice_5_59_0'    \/>\n\t\t\t\t<label for='choice_5_59_0' id='label_5_59_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_59_1'>\n\t\t\t\t<input name='input_59' type='radio' value='Non'  id='choice_5_59_1'    \/>\n\t\t\t\t<label for='choice_5_59_1' id='label_5_59_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_5_60\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Y a-t-il des proc\u00e9dures judiciaires en cours\u202f?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_60'>\n\t\t\t<li class='gchoice gchoice_5_60_0'>\n\t\t\t\t<input name='input_60' type='radio' value='Oui'  id='choice_5_60_0'    \/>\n\t\t\t\t<label for='choice_5_60_0' id='label_5_60_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_60_1'>\n\t\t\t\t<input name='input_60' type='radio' value='Non'  id='choice_5_60_1'    \/>\n\t\t\t\t<label for='choice_5_60_1' id='label_5_60_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_5_61\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Y a-t-il une ordonnance de protection en vigueur\u202f?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_61'>\n\t\t\t<li class='gchoice gchoice_5_61_0'>\n\t\t\t\t<input name='input_61' type='radio' value='Oui'  id='choice_5_61_0'    \/>\n\t\t\t\t<label for='choice_5_61_0' id='label_5_61_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_61_1'>\n\t\t\t\t<input name='input_61' type='radio' value='Non'  id='choice_5_61_1'    \/>\n\t\t\t\t<label for='choice_5_61_1' id='label_5_61_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_5_62\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Y a-t-il une condamnation criminelle<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_62'>\n\t\t\t<li class='gchoice gchoice_5_62_0'>\n\t\t\t\t<input name='input_62' type='radio' value='Oui'  id='choice_5_62_0'    \/>\n\t\t\t\t<label for='choice_5_62_0' id='label_5_62_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_62_1'>\n\t\t\t\t<input name='input_62' type='radio' value='Non'  id='choice_5_62_1'    \/>\n\t\t\t\t<label for='choice_5_62_1' id='label_5_62_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_5_63\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_63'>Raison de la condamnation criminelle<\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_5_63' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_64\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >DISPOSITIONS DE VISITES ANT\u00c9RIEURES<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_5_64'><li class='gchoice gchoice_5_64_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.1' type='checkbox'  value='Acc\u00e8s supervis\u00e9'  id='choice_5_64_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_64_1' id='label_5_64_1' class='gform-field-label gform-field-label--type-inline'>Acc\u00e8s supervis\u00e9<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_64_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.2' type='checkbox'  value='Acc\u00e8s non supervis\u00e9'  id='choice_5_64_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_64_2' id='label_5_64_2' class='gform-field-label gform-field-label--type-inline'>Acc\u00e8s non supervis\u00e9<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_64_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.3' type='checkbox'  value='Pas d\u2019acc\u00e8s ant\u00e9rieur'  id='choice_5_64_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_64_3' id='label_5_64_3' class='gform-field-label gform-field-label--type-inline'>Pas d\u2019acc\u00e8s ant\u00e9rieur<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_5_65\" class=\"gfield gfield--type-date gfield--input-type-datedropdown field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Dernier acc\u00e8s<\/label><div id='input_5_65' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_5_65_1_container'><label for='input_5_65_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Mois<\/label><select aria-describedby='field_5_65_dmessage' name='input_65[]' id='input_5_65_1'   aria-required='false'  ><option value=''>Mois<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_5_65_2_container'><label for='input_5_65_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Jour<\/label><select aria-describedby='field_5_65_dmessage' name='input_65[]' id='input_5_65_2'   aria-required='false'  ><option value=''>Jour<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_5_65_3_container'><label for='input_5_65_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Ann\u00e9e<\/label><select aria-describedby='field_5_65_dmessage' name='input_65[]' id='input_5_65_3'   aria-required='false'  ><option value=''>Ann\u00e9e<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_5_66\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Informations importantes lors de la soumission d\u2019une demande<br><br>1) Chaque parent\/tuteur doit remplir et soumettre un formulaire de demande s\u00e9par\u00e9.\n2) Vous recevrez une confirmation que nous avons bien re\u00e7u votre demande. Une fois que les deux demandes auront \u00e9t\u00e9 re\u00e7ues, un rendez-vous d\u2019admission sera planifi\u00e9.\n3)Lors de l\u2019admission, vous devrez fournir une copie de votre ordonnance du tribunal, des proc\u00e8s-verbaux de r\u00e8glement, de l\u2019approbation ou de l\u2019accord de m\u00e9diation, en plus de tout document relatif \u00e0 la protection de l\u2019enfance, aux ordonnances de restriction pass\u00e9es ou actuelles, aux conditions de mise en libert\u00e9 sous caution et aux preuves de revenu, le cas \u00e9ch\u00e9ant.\n4) Les demandes envoy\u00e9es par Internet ne peuvent pas \u00eatre garanties comme \u00e9tant 100 % s\u00e9curis\u00e9es. Si vous avez des pr\u00e9occupations concernant la confidentialit\u00e9, veuillez contacter le coordonnateur au (705) 945-5058 poste 2707. <\/li><li id=\"field_5_67\" class=\"gfield gfield--type-captcha field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_67'>CAPTCHA<\/label><div id='input_5_67' class='ginput_container ginput_recaptcha' data-sitekey='6Leb9CQaAAAAAO79BP3KZnnHroUGaH8YtI3ch8GE'  data-theme='light' data-tabindex='-1' data-size='invisible' data-badge='bottomright'><\/div><\/li><\/ul><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_5' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='submit' id='gform_submit_button_5' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Soumettre'  \/> <input type='hidden' name='gform_ajax' value='form_id=5&amp;title=&amp;description=&amp;tabindex=49&amp;theme=legacy&amp;styles=[]&amp;hash=b7f4ebe81fa26e6ae0716ecc00505f79' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_5' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_5' id='gform_theme_5' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_5' id='gform_style_settings_5' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_5' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='5' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='CAD' value='Mm3zfA9m1DVBXUQNr1U2vtCq24T1E6ePif1kMAdjo8L+npZam73AoJMCmy+Jd620F9x1e7vy7xx2Hbs4HFTq6pB30200BqePhFzE3wsFfwF3Z1M=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_5' value='WyJbXSIsIjEyNGQwZDdlNGNkOGM4Y2ViNzMxY2VmMzgxOWY4NjFlIl0=' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_5' id='gform_target_page_number_5' value='2' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_5' id='gform_source_page_number_5' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n             <\/div><\/div>\n                        <\/form>\n                        <\/div>\n\t\t                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_5' id='gform_ajax_frame_5' title='Cette iframe contient la logique n\u00e9cessaire pour manipuler Gravity Forms avec Ajax.'><\/iframe>\n\t\t                <script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 5, 'https:\/\/algomafamilyservices.ca\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_5').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_5');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_5').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_5').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_5').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_5').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_5').offset().top - 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